Confident Canine History Intake Form

Intake History Form

Nina Fotara - The Holistic Gundog Specialist
Data information:

Information entered on this form will be saved securely in order to process your query, booking &/or consultation. It will also be entered to our booking system (Ovatu) to allow appointment confirmation to be sent to yourself.
Programs
Have you looked at our programs on the website yet and were you drawn to one in particular? If yes, which program was that and why?
Your Information
Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Regular Veterinarian
Clinic*
Veterinarian name
Phone Number*

Area CodePhone Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Dogs Details
What is your dogs name?*
What is your dogs breed? or cross or mix if known*
What is your dogs age? or date of birth*
Weight (approximate if unsure)*
Sex*
Are they spayed or neutered? If YES at what age?*
What was the reason for desexing/not desexing your dog?*
Does your dog have any medical conditions (Yes/No and please explain if yes) ?*
Is your dog currently on any medications? (Yes/No and please explain if yes) ?*
Previous History
How old was your dog when you acquired them?*
Where did you get your dog from?*
Has your dog had previous owners? (Yes/No and if yes do you know why they were rehomed?)*
Do you have any information about relatives of your dog?*
Why did you choose this breed or crossbreed or type of dog in particular?*
Have you owned other dogs before? (Yes/No and if yes what happened to them)*
Problem Behaviours
What are the 3 main issues you experience with your dog in order of priority?*
What is the problem that made you contact me?*
How would you describe the severity of the problem?*

MildModerateSevere
How would you describe the frequency of the problem?*

RareOftenFrequently
Has their been any noticeable change in severity?*
Has their been any noticeable change in frequency?*
When &/or how did the problem begin?*
How old was your dog when the problem begun?*
Have you ever considered euthanasia/rehoming?*
Please subjectively rate your perception of the main behaviour problem:*

Not serious: I am just curious about the behaviourNuisance but tolerableSerious but I would keep my dog if the behaviour persistsNot tolerable: I may rehome my dog if the behaviour persistsNot tolerable: I may euthanise my dog if the behaviour persists
Family
Describe your family (Please include person detail (i.e. name and spouse, mother etc), age, M/F, occupation and time away from home daily)*
In your own words describe the family dynamics in relationship to your dog(s).....*
Other pets (Please include name, species/breed, sex, age and when did you get them*
In your own words describe the family dynamics in relationship to your dog(s) and your other pets....*
Previous History
How often do you walk your dog and for how long?*
What kind of formal training has your dog had?*
Who trains your dog?*
What have you tried in the past to help the problem behaviour(s)?*
What time(s) of day do you feed your dog?*
What do you feed your dog?*
Describe your dogs eating habits?*
How does your dog react when he see's unfamiliar people? (i.e. growls, nips, bites, avoids, humps, excited, jumps, friendly etc) - Please list all that apply*
How does your dog react when he see's unfamiliar dogs? (i.e. growls, nips, bites, avoids, humps, excited, jumps, friendly etc) - Please list all that apply*
Has your dog ever nipped? (Yes/No)*
How many times?
If yes please describe incidents below......
Has your dog ever bitten? (Yes/No)*
How many times?
If yes please describe incidents below......
Has your dog broken skin with a bite? (Yes/No)*
How many times?
If yes please describe incidents below......
Is there anything else you think may be relevant to your dog that I may need to know?
Emergency Contacts
Emergency Contacts Name*

First NameLast Name
Emergency Contacts Phone Number - Mobile*

Area CodePhone Number
Emergency Contacts Phone Number - Landline

Area CodePhone Number
Emergency Contacts Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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Have you ever trained with Nina (The Holistic Gundog Specialist) before? If yes, what did you do?*
Date*

MonthDayYear
Signature*

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Type a question
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Intake History Form

Data information:

Programs

Your Information

Regular Veterinarian

Your Dogs Details

Previous History

Problem Behaviours

Family

Previous History

Emergency Contacts

Sign off